PRINCIPLES OF TREATMENT OF FRACTURES

GOALS OF FRACTURE TREATMENT

Restore the patient to optimal functional state Prevent fracture and soft-tissue complications Get the fracture to heal, and in a position which will produce optimal functional recovery Rehabilitate the patient as early as possible

HOW FRACTURES HEAL

In nature
Regeneration vs repair Three phases of healing by callus Rapid process, rehabilitation slow, low risk

With operative intervention (reduction + compression)

Primary bone healing Slow process, rehabilitation rapid, high risk

With operative intervention (nailing or external fixation)

Healing by callus Rapid process, rehabilitation rapid, lesser risk

FACTORS AFFECTING FRACTURE HEALING

The energy transfer of the injury The tissue response
Two bone ends in opposition or compressed Micro-movement or no movement BS (scaphoid, talus, femoral and humeral head) NS No infection

The patient The method of treatment

HIGH-ENERGY INJURY

LOW ENERGY INJURY

DESCRIBING THE FRACTURE

Mechanism of injury (traumatic, pathological, stress)
Anatomical site (bone and location in bone) Configuration Displacement
three planes of angulation translation shortening

Articular involvement/epiphyseal injuries

fracture involving joint dislocation ligamentous avulsion

Soft tissue injury

MINIMALLY DISPLACED DISTAL RADIUS FRACTURE

COMMINUTED PROXIMALTHIRD FEMORAL FRACTURE WITH SIGNIFICANT DISPLACEMENT

MANAGEMENT OF THE INJURED PATIENT

Life saving measures
Diagnose and treat life threatening injuries Emergency orthopaedic involvement
Life saving Complication saving

Emergency orthopaedic management (Day 1) Monitoring of fracture (Days to weeks) Rehabilitation + treatment of complications (weeks to months)

LIFE SAVING MEASURES

A B C D E Airway and cervical spine immobilisation Breathing Circulation (treatment and diagnosis of cause) Disability (head injury) Exposure (musculo-skeletal injury)

EMERGENCY ORTHOPAEDIC MANAGEMENT

Life saving measures
Reducing a pelvic fracture in haemodynamically unstable patient Applying pressure to reduce haemorrhage from open fracture

Complication saving
Early and complete diagnosis of the extent of injuries Diagnosing and treating soft-tissue injuries

DIAGNOSING THE SOFT TISSUE INJURY

Skin
Open fractures, degloving injuries and ischaemic necrosis

Muscles
Crush and compartment syndromes

Blood vessels
Vasospasm and arterial laceration

Nerves
Neurapraxias, axonotmesis, neurotmesis

Ligaments
Joint instability and dislocation

SEVERE SOFT-TISSUE INJURY

TREATING THE SOFT TISSUE INJURY

All severe soft tissue injuries treatment equire urgent

Open fractures , Vascular injuries, Nerve injuries, Compartment syndromes, Fracture/dislocations

After the treatment of the soft tissue injury the fracture requires rigid fixation A severe soft-tissue injury will delay fracture healing

DIAGNOSING THE BONE INJURY

Clinical assessment
History Co-morbidities Exposure/systematic examination

First-aid reduction Splintage and analgesia Radiographs

Two planes including joints above and below area of injury

TREATING THE FRACTURE I

Does the fracture require reduction?
Is it displaced? Does it need to be reduced? (e.g. clavicle, ribs, MT s)

How accurate a reduction do we need?

alignment without angulation (closed reduction - e.g. wrist) anatomic (open reduction - e.g. adult forearm )

TREATING THE FRACTURE II

How are we going to hold the reduction?
Semi-rigid (Plaster) Rigid (Internal fixation)

What treatment plan will we follow?

When can the patient load the injured limb? When can the patient be allowed to move the joints? How long will we have to immobilise the fracture for?

DIFFERENT TYPES OF RIGID FRACTURE FIXATION

TREATING THE FRACTURE III

Operative
Rehabilitation Risk of joint stiffness Risk of malunion Risk of non-union Speed of healing Risk of infection Cost Rapid Low Low Present Slow Present ?

Non-optve
Slow Present Present Present Rapid Low ?

INDICATIONS FOR OPERATIVE TREATMENT

General trend toward operative treatment last 30 yrs
Improved implants and antibiotic prophylaxis, Use of closed and minimally invasive methods

Current absolute indications:Polytrauma Displaced intra-articular fractures Open # s # s with vascular inj or compartment syn, Pathological # s Non-unions

Current relative indications:Loss of position with closed method, Poor functional result with nonanatomical reduction, Displaced fractures with poor blood supply, Economic and medical indications

WHEN IS THE FRACTURE HEALED?

Clinically
Upper limb Adult Child 6-8 weeks 3-4 weeks Lower limb 12-16 weeks 6-8 weeks

Radiologically
Bridging callus formation Remodelling

Biomechanically

REHABILITATION
Restoring the patient as close to pre-injury functional level as possible
May not be possible with:Severe fractures or other injuries Frail, elderly patients

Approach needs to be:Pragmatic with realistic targets Multidisciplinary

Physiotherapist, Occupational therapist, District nurse, GP, Social worker

COMPLICATIONS OF FRACTURES
Early
General Other injuries PE FES/ARDS Bone Infection UTI Bed sores Non-union Malunion AVN Soft-tissues Plaster sores/WI N/V injury Tendon rupture Nerve compression

Late
Chest infection

Compartment syn. Volkmann contracture